MA Behavioral Health Partnership

Massachusetts Hospital Association and Massachusetts College of Emergency Physicians
Status Report of Ongoing Issues with the Massachusetts Behavioral Health Partnership

Background
The Massachusetts Behavioral Health Partnership (the "Partnership") was selected in 1996 as the managed care carve-out company responsible for managing mental health and substance abuse benefits for Medicaid (now called "MassHealth") enrollees. As the Partnership began operations in the state, they developed numerous policies that had a direct effect on the operations of emergency departments in Massachusetts hospitals. Unfortunately, these policies were sometimes developed or implemented with little or no input from the field of emergency medicine. In October 1997, representatives of MHA and MACEP met with the Partnership to discuss these issues; we also agreed to continue to meet with the Partnership as an ad-hoc group, on an ongoing basis, as necessary. Following is a list of major issues that we have raised with the Partnership, and their resolution (if any).

Credentialing
The emergency screening teams which assess the appropriateness of an admission of a patient with a psychiatric chief complaint are contract employees for the state of Massachusetts and have no formal affiliation with Massachusetts hospitals. Several members were concerned that individuals on these teams were effectively making admission decisions even though they were not credentialed at the hospitals at which they were assessing patients. We decided early on that we would not challenge the existence of the teams (even though in the vast majority of cases the screening teams agree with the treating physician on the need for an admission). However, we did work with JCAHO to develop a credentialing policy that would not pose accreditation problems.

ED Wait Times
Several emergency physicians expressed concern over the wait times for psychiatric patients in their departments (largely attributable to the screening teams). We agreed on a policy under which hospitals should not be forced to wait more than one hour between completion of an assessment of a patient by an emergency physician and the arrival of the screening teams to the Emergency Department. If hospitals are kept waiting more than that time, the Partnership has made available a toll-free "emergency" number to secure authorization for an immediate admission of the patient.

* Hospitals report that this policy worked for a time. Recently, however, wait times appear to be increasing again. Furthermore, the screening teams seem to have overly bureaucratic policies that needlessly increase wait times (e.g., one MassHealth patient presents in an ED with a psychiatric chief complaint; 15 minutes later, another arrives; two different screening teams have to be called to assess each patient.

Need to Obtain Toxicology Screens for Psychiatric Patients
Emergency physicians expressed concern that hospitals to which a patient was to be transferred (often private psychiatric hospitals) were requesting toxicology screens and blood serum levels before accepting a transfer, even though blood tests were not medically indicated. The Partnership initially believed that good medical policy dictated that the tests be done by the hospital at which the patient initially presented. However, after objections by emergency physicians, the Partnership agreed to form a joint task force with representatives of MACEP and the Massachusetts Psychiatric Society to develop a toxicology screen policy, and implement it if there was agreement. MACEP and MPS agreed on a tox screen policy, the central premise of which was that tox screens were at the discretion of the sending institution . As promised, the Partnership implemented this policy.

* MHA and the Partnership published this policy. Although there appears to be some success in educating the screening teams on the new policy, transferee hospitals appear to continue to ignore it. The Partnership has agreed to re-publish the MACEP/MPS task force recommendations and hold their contractors accountable for adhering to it.

Medical Clearance
There is significant debate in the medical literature over the point at which a patient an be considered "medically clear" and referred to psychiatry for a consult (or, which patients can be sent directly to psychiatry after triage and vital sign measurement). See Tintinalli, Peacock and Wright, Emergency Medical Evaluation of Psychiatric Patients , ANN. EMERG. MED. 23:859-62 (April 1994) and Korn, Currier and Henderson, "Medical Clearance" of Psychiatric Patients Without Medical Complaints in the Emergency Department , JOURNAL OF EMERG. MED. 18:173-176 (Feb. 2000). The Partnership agreed to form another MACEP/MPS task force to develop a policy on medical clearance that would identify those patients who can be sent directly to psychiatry after a threshold screening examination. As of May 2000, the policy is close to completion.

Partnership's Free Care Policy and Conflicts with EMTALA
After they began operations in the state, the Partnership developed a "no reject" free care policy under which network hospitals could not refuse to treat a psychiatric patient with no health insurance. Network hospitals were expected to admit, and treat, uninsured patients. The Partnership developed several iterations of this policy; at one point, they developed a "mini" free care pool under which network hospitals would pay into (and receive payments from) a psychiatric free care pool. After MHA objected, the pool concept was abandoned, and the Partnership issued a Network Alert that flatly forbade hospitals from rejecting free care patients. However, this policy, as drafted, seemed to excuse private psychiatric hospitals from the "no reject" policy. MHA and MACEP persuaded the Partnership that such a policy was a clear violation of EMTALA; private psychiatric hospitals cannot refuse a transfer request if they participate in the Medicare program. In response to those concerns, the Partnership amended the policy.

Psychiatric Stabilization
The discussion over the Partnership's free care policy led to a larger discussion over when it was appropriate to transfer a psychiatric patient for economic reasons. This is of more than academic interest, since Partnership network hospitals are expected to "stabilize free care patients consistent with EMTALA guidelines." Since "stabilization" of psychiatric patients under EMTALA has never been clear, we told the Partnership that they needed to work with us to develop stabilization guidelines. We have so far done a literature and case law search (I presented the results at a MACEP meeting earlier this year), and have had one further meeting with the Partnership. We are asking the Partnership to develop an "observation" rate to reimburse non-network hospitals that are forced to admit psychiatric patients through EMTALA stabilization (however we define that term). That process is still ongoing.

Pediatric Psychiatry Issues
The Partnership is aware, as is DMH and DMA, of the crisis with pediatric psychiatry in this state. Based on intervention from MHA, MACEP, and the private psychiatric hospitals, the Partnership has agreed to pay hospitals (including non-network hospitals) who are forced to "board" children in the emergency departments or on a pediatric medical floor awaiting an inpatient pediatric psychiatric bed.

* Although this policy has been adopted and announced, it is not clear that any billing guidelines have been issued so that hospitals can actually be paid for the services they provide.